Student, Thank you for your interest in our continuing education healthcare courses. Below you will find pre-admission information relevant to our. This application packet must be completed and returned to the CE Health Sciences department at the Courtyard Center prior to registering for classes. Submit copies only, documents will not be returned. We will not be able to provide a copy back to you after submission, so please keep your originals. As of March, 2017, Collin College will no longer accept copies of vaccine records. This documentation will be collected by ArcPoint Labs, verified, and consolidated into a standardized format. See page 5 for details. Please return completed application forms, vaccine printout from ArcPoint labs (new process as of March, 2017), and copies of your ID and Basic Life Support Card to the CE Health Sciences Office, Courtyard Center in Plano, Texas between the hours of 8AM and 5PM, Monday through Friday. If needed, the documents may be faxed to 972.985.3782 or emailed to CEHealthcare@collin.edu. Applications are reviewed twice a week by the review committee. Please use the following chart to determine when your application will be reviewed based on your submission date. Students will be emailed on Tuesday or Friday by 5pm with approval or with a request to submit additional documentation. Day Application is submitted Method of submission Day applications are reviewed Day student will be emailed Monday In-person, Fax, Email Tuesday Tuesday, by 5pm Tuesday In-person, Fax, Email Friday Friday, by 5pm Wednesday In-person, Fax, Email Friday Friday, by 5pm Thursday In-person, Fax, Email Friday Friday, by 5pm Friday In-person, Fax, Email Tuesday Tuesday, by 5pm Saturday Fax, Email Tuesday Tuesday, by 5pm Sunday Fax, Email Tuesday Tuesday, by 5pm Thanks again, and we look forward to working with you on your healthcare career goals! Sincerely, The CE Healthcare Team March 23, 2017 Phlebotomy Page 1 of 5
Step 1: Step 2: Step 3: Step 4: Step 5: Step 6: Checklist Complete the application information on page 3, read the Statements of Understanding, sign and date the bottom. Complete the consent form on pg 4. Go to ArcPoint for a background check. See page 5 for detailed instructions. Cost for this service is $45. Go to ArcPoint to submit for a drug test. Map and instructions are on page 5. Cost for this service is approximately $30. Results of these 2 checks are provided directly to Collin College in about 3 days. As of March, 2017, all students must submit all vaccine documentation to ArcPoint for verification, not Collin College. See page 5 for a map and detailed instructions. Cost for this service is $30. Required vaccines are: MMR 2 doses (in accordance with CDC requirements) or positive titers through bloodwork Varicella 2 doses (in accordance with CDC requirements) or positive titers through bloodwork Hepatitis B 2 doses (in accordance with CDC requirements) or positive titers through bloodwork Tetanus 1 dose within the past 10 years Tuberculosis negative skin test or chest X-ray within the past 12 months Flu current year s flu vaccine (Sept-April only) Copy the front and back of your Basic Life Support card and State issued ID. If you do not have a card, please visit http://www.collin.edu/ce/courses/bls.html as we offer this course frequently. You will need to register and pay for the course, attend class and pass your exams to receive your BLS card and be eligible for participation in one of the training programs. Submit all documentation to the CE Health Sciences Department. We need: Pages 3 and 4 of this application packet, Vaccine printout from ArcPoint labs, (new process in Step 3) Copy of State issued ID, Copy of Basic Life Support card. These vaccines can be obtained at your doctors office, the county health department, ArcPoint labs, and some pharmacies. March 23, 2017 Phlebotomy Page 2 of 5
Name: Mailing address: Preferred phone: E-mail address: By signing below, I agree to the following Statements of Understanding: CWID or Birthdate: City: Other languages: Course Start : I have attached the required documentation for consideration, including the vaccine printout from ArcPoint Labs. I have read and understand the rules and regulations of the college and the program and will abide by these as terms of my continuation in the program. The information I have given in this application is factual, and I understand that falsification of any required documentation will result in the denial of my application or removal from class. I understand that I must obtain and pay for liability insurance prior to attending class. I understand this insurance is NOT health insurance. This insurance is provided through Collin College and will be charged to my account at the point of registration. (Fee ranges from $5-$13, depending on date of enrollment.) I have read and understand the potential for exposure to blood or other potentially infections materials (information available at http://www.cdc.gov/hepatitis/hbv/index.htm) or exposure to inhalation of airborne microorganisms (smallpox, tuberculosis, latex ) and I will not hold Collin College liable for any accidental exposure I may experience. I have read and understand the terms related, and release Collin College and its employees from any liability. I understand that this type of course/career has specific physical requirements, which may include lifting up to 25 pounds. I understand that if I don t successfully complete and pass each requirement for admissions, my application will be declined. I understand that enrollment in these courses is limited, and seats will be awarded in date order based on those students who complete, turn in, and pass all pre-admission requirements. I understand that I must successfully complete competencies in the classroom portion of my training and maintain at least 90% classroom attendance to pass the course and be eligible for clinicals. Recommendations from my instructors will also be a contributing factor to eligibility. Signature: : Collin College does not discriminate on the basis of race, color, religion, age, sex, national origin, disability or veteran status. March 23, 2017 Phlebotomy Page 3 of 5
(For Phlebotomy Students Only) Invasive Procedures Consent Form I, (Student Name) understand that during the course of my program of study, I will have the opportunity to practice specific invasive procedures on consenting students. The invasive procedures that may be practiced are limited to venipuncture and skin puncture. I understand that a clinical faculty member must be in attendance during any practice session in which venipuncture or skin puncture are practiced. I will not perform, nor allow to be performed on me, any practice session in which venipuncture or skin puncture are performed unless a clinical faculty member is present. I understand that receiving venipuncture or skin puncture administered by other students is strictly voluntary and will not impact my grade. I understand that the risks of these procedures may include infection, feeling light-headed, bruising, or other damage to tissue or nerves. I hereby release, and will not hold Collin County Community College District, its directors, officers, executives, board members, faculty, employees, nor my classmates liable for any injury or complication that may result from any and all activity occurring in practice sessions. I give my consent for students to practice, or faculty to demonstrate, venipuncture and/or skin punctures on me. Student Signature I understand that declining consent requires my practice be limited to practicing on mannequin arms only. I will not perform venipuncture or skin puncture on the mannequin arm unless a clinical faculty member is present, as there are risks associated with any performance of venipuncture and skin puncture. I understand that the risks of these procedures may include infection, feeling light-headed, bruising, or other damage to tissue or nerves. I hereby release, and will not hold Collin County Community College District, its directors, officers, executives, board members, faculty, employees, nor my classmates liable for any injury or complication that may result from any and all activity occurring in practice sessions. I decline to have students practice, or faculty to demonstrate, venipuncture and/or skin punctures on me. I will be limited to practicing on mannequin arms only. Student Signature Reviewed by: Collin College Representative Signature Note: If the student wishes to change his/her consent at any time during the program, a new form must be signed and dated and approved by a Collin College Representative. March 23, 2017 Phlebotomy Page 4 of 5
ArcPoint Student Background Check Instructions All students applying for admission to specific healthcare programs must complete a student background check through ArcPoint. The cost of this service is $45. Typical background reports will take 2-4 business days to complete. All information is considered confidential and as such will not be used for any purposes other than to determine an applicant s eligibility. ArcPoint Drug Screening Instructions Organization/Company Collin College Continuing Education in accordance with their policies hereby require you to go to ArcPoint to complete drug screening. The cost of this service is approximately $30. ArcPoint Vaccine Verification Instructions, (as of March, 2017,) Go to ArcPoint Labs and submit all of your vaccine documentation. These documents should not be submitted to Collin College. Submit copies only, documents will not be returned. ArcPoint Labs will collect documentation on the following vaccines: MMR 2 doses (in accordance with CDC requirements) or positive titers through bloodwork Varicella 2 doses (in accordance with CDC requirements) or positive titers through bloodwork Hepatitis B 2 doses (in accordance with CDC requirements) or positive titers through bloodwork Tetanus 1 dose within the past 10 years Tuberculosis negative skin test or chest X-ray within the past 12 months Flu current year s flu vaccine (Sept-April only) This documentation will be collected by ArcPoint Labs, verified, and consolidated into a standardized format. The cost of this service is $30. Collect the vaccine printout form from ArcPoint Labs and submit to the CE Health Science office along with your other paperwork. March 23, 2017 Phlebotomy Page 5 of 5